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There was an article from the The Atlantic website entitled “The Last Days of the President: LBJ in retirement” by Leo Janos from a July 1973 Issue and this is what was written:On the night before Christmas, 1971, Lyndon Baines Johnson played the most improbable role of his varied and controversial life. Protected from public view behind the gates of his Texas ranch, and no longer suffering the cloying presence of a battalion of White House reporters, Johnson donned a red suit and false beard, climbed aboard a small tractor, and drove to the hangar adjoining his airstrip. Assembled inside were the families of his ranch hands for what had become a traditional ceremony over the years: receiving greetings and gifts from LBJ. This time, they were so stunned at the sight of the former President ho-ho-hoing aboard a chugging tractor that they greeted his arrival with disbelieving silence. Undeterred, Johnson dismounted the tractor and unloaded a bag of toys for the children, sent to him for the occasion by an old friend, New York toy manufacturer Louis Marx, father of Patricia Marx Ellsberg."I'm going to enjoy the time I've got left," Johnson told friends when he left Washington in January, 1969, a worn old man at sixty, consumed by the bitter, often violent, five years of his presidency. He had never doubted that he could have won the 1968 election against Richard Nixon if he had chosen to run for another term. But in 1967 he launched a secret actuarial study on his life expectancy, supplying personal histories of all the males in the recent Johnson line, himself included. The men in the Johnson family have a history of dying young," he told me at his ranch in the summer of 1971, "My daddy was only sixty-two when he died, and I figured that with my history of heart trouble I'd never live through another four years. The American people had enough of Presidents dying in office." The prediction handed to Johnson was that he would die at the age of sixty-four. He did.He returned to the Texas hill country so exhausted by his presidency that it took him nearly a full year to shed the fatigue in his bones. From the outset he issued the sternest orders to his staff that the press was to be totally off limits. "I've served my time with that bunch," he said, "and I give up on them. There's no objectivity left anymore. The new style is advocacy reporting—send some snotty-nosed reporter down here to act like a district attorney and ask me where I was on the night of the twenty-third. I'm always guilty unless I can prove otherwise. So to hell with it." His press grievances were usually accompanied by favorite examples of anti-Johnson stacked decks—among these, the flurry of comment generated when he had lifted his shirt to expose ample belly and fresh surgical scar. He explained: "Rumors were flying that I really had cancer. I had to prove I really had my gall bladder taken out." By contrast Nixon, he thought, had intimidated the press into fair treatment. "The damn press always accused me of things I didn't do. They never once found out about the things I did do," he complained with a smile. One result of such self-righteous bitterness was that the man who had been the world's most powerful and publicized ruler was simply swept down a hole of obscurity, surfacing only occasionally at University of Texas football games or at the funerals of old friends such as Hale Boggs and Harry Truman. A logical surmise was that Johnson was brooding in silence on his ranch porch, pouting at the unfriendly, unloving world beyond his guarded gates. But LBJ's temperament was more complicated than that: relaxed, easy, and friendly for days, he would suddenly lapse into an aloof and brooding moodiness, only to give way to a period of driving restlessness. He was a seesawing personality for as long as anyone could remember.His first year in retirement was crowded with projects. He supervised nearly every construction detail of the massive LBJ Library complex on the University of Texas campus, which houses not only thirty-one million documents acquired over thirty-eight years in Washington, but also the LBJ School of Public Affairs. At one point, university regent Frank Erwin approached Johnson about an Indiana educator who was interested in running the LBJ School. Johnson frowned at the mention of the state which sent to the Senate one of Johnson's least favorite persons, and among the most vocal of his war critics, Vance Hartke. "Frank," Johnson responded, "I never met a man from Indiana who was worth a shit."There was fresh bitterness over a series of hour-long interviews, with Walter Cronkite for which Johnson had contracted with CBS before leaving the White House. The first show, on Vietnam, had been a fiasco. "I did lousy," Johnson admitted, and raised hell over what he claimed had been an unfair CBS editing practice—Cronkite refilming new questions to answers he had originally given during the interview at the ranch. "Cronkite came down here all sweetness and light, telling me how he'd love to teach journalism at Texas someday, then he does this to me," he fumed. The critical reaction to his television interview on Vietnam reinforced Johnson's conviction that his presidential memoirs should be divided into two separate books, one on domestic policies, the other on foreign affairs. In this way, he reasoned, the Great Society would be spared from the critical response he anticipated to his explanations of Vietnam policy. His publishers talked him out of separate books, and Johnson cautiously began unfolding his version of his presidential years. Assisted by two trusted staff writers, Robert Hardesty and William Jorden, he issued only one firm guideline, that not one word should appear in the book that could not be corroborated by documentation. To aid in this effort, Johnson threw open to his writers every file and document from his White House years, including telephone conversations he had held as President, which were recorded and transcribed for history. (Exposure to this material was largely for his writers' background information; few revelations or previously unpublished documents appeared in Johnson's book.) Jorden, a former New York Times reporter who had worked as an assistant to Walt Rostow, was particularly impressed with his research reading. "My God," he said, "I thought I knew just about everything involving Vietnam during my White House days. I discovered that I had missed a lot."William Jorden worked on the book's Vietnam chapters, which went to twenty drafts, and were read by McGeorge Bundy, Generals Earle Wheeler and William Westmoreland, and Abe Fortas, LBJ's pre-eminent confidant, among others, before receiving final approval. The result of all this effort was a fully researched but flat and predictable apologia of the Johnson years, most of its vital juices evaporated many drafts ago.Hurt and disappointed by the adverse critical reaction to his book, The Vantage Point: Perspectives of the Presidency, 1963-1969, Johnson found solace working the land of his 330-acre ranch, which he bought in 1951. Under a fiery Texas sun, the Pedernales River runs clear and full. Fat cattle graze languidly in the shade of live oaks. Johnson knew that he owned some of the loveliest property in Texas, and unleashed his energies as a working rancher like a restless child entering a playpen. LBJ installed a complex irrigation system (and was observed clad only in paper shorts helping to lay pipe in the middle of the shallow Pedernales), constructed a large hen house, planted acres of experimental grasses sufficiently hardy to withstand severe hill country weather, and built up his cattle herds through shrewd purchases at the weekly cattle auctions near Stonewall. On one occasion, ranch foreman Dale Milenchek talked Johnson into purchasing an $8000 breeding bull. The massive animal impregnated only a few cows before suffering a fatal leg infection. Johnson complained, "Dale bought me the most expensive sausage in the history of Texas."No ranch detail escaped his notice. Once, driving some friends around the spread, LBJ suddenly reached for his car radiophone, which crackled just as much in retirement as it had when he was President. "Harold, Harold, over," he barked. "Why is that sign about selling the Herefords still posted? You know we sold them last week. Get it down." At the LBJ State Park, across the road, Johnson enjoyed escorting his guests to a slide show and exhibit on the hill country. On another occasion, I observed Johnson watching a preview of a new slide show with increasing annoyance as the bearded face of a local Stonewall character appeared in various poses, slide after slide. Turning angrily to his park supervisor, Johnson exclaimed: "Will you please tell me why we need six slides of Hondo Crouch?" Another must on a Johnson-chauffeured tour was the family graveyard, a few hundred yards from his home. "Here's where my mother lies," he solemnly declared. "Here's where my daddy is buried. And here's where I'm gonna be too." Then, a sudden acceleration and the white Lincoln Continental would roar to the cow pastures.Old friends invited to dine with the squire of the Pedernales would be advised that dinner was at eight. But not until ten or eleven would Johnson appear, happily tired and dung-booted, to regale his guests about the new calf or progress with his egg production. "He's become a goddamn farmer," a friend complained. "I want to talk Democratic politics, he only talks hog prices." Often, Johnson took friends to a favorite hill on his spread to watch the sunset. His Secret Service bodyguard, Mike Howard, unpacked an ice chest and glasses, and the group would relax and drink to the setting sun. Meanwhile, back at the ranch, cook Mary Davis, a keenly intelligent black lady, would begin pressuring Lady Bird to get Johnson and his guests back before dinner was ruined. "Another half hour and I simply cannot be responsible for this roast," Mary would complain. With a sigh, Lady Bird would begin the artful manipulation of her husband. Contacting him on the car radio, she would suggest: "Honey, why don't you take everyone over to Third Fork and show them the deer?" (Third Fork was only a quarter of a mile away, in the direction of home.) Such ploys often failed, however. "Damn it," Johnson would reply, "I'm not going to be pressured into keeping to anyone's schedule but my own."He was still very much "Mr. President" to the retinue serving him in retirement, including three round-the-clock Secret Service protectors, a Chinese butler named Wong, brought to Texas from the White House, two secretaries, a dozen former White House staffers, who worked at the library but could be tapped for other duties when the occasion demanded, as well as a dozen or so ranch hands who were kept scrambling. A phone call would dispatch an Air Force helicopter to carry him forty miles from his ranch into Austin, where a landing pad had been built on the library roof. For longer trips he used his own twin-engine turboprop. A visitor expressed surprise that LBJ could still summon a helicopter to fly him around the Austin area. An aide responded, "He was living this way when he was in the Senate."He took up golf, puttering around courses in Fredericksburg, and on trips to Mexico. One day, playing with a few aides and friends, Johnson hit a drive into the rough, retrieved it, and threw the ball back on the fairway. "Are you allowed to do that?" one of the wives whispered to a Secret Service agent. "You are," he replied, "if you play by LBJ rules."Each December 21 he would host a rollicking party at the Argyle Club in San Antonio to celebrate his wedding anniversary. The guest list was limited to his closest friends, including a Texas businessman named Dan Quinn, who on the day of the wedding had had to run out and buy a ring for Lyndon to give to Lady Bird, since the groom had forgotten that particular detail. The hired band was instructed to play danceable music only, and Johnson, a classy ballroom dancer of the first rank, would dance with every lady present into the wee hours.Each February Johnson would take over a seaside villa in Acapulco for a mouth's siege. The exquisite estate is owned by former Mexican President Miguel Alemán, a business partner with LBJ on several Mexican ranchland deals. Johnson would fly in family, friends, and aides, as well as his own cook, food, bottled water, and even air-conditioning units. He brought his own food, water, and liquor to Acapulco to avoid the embarrassment of his 1970 trip when nearly all of his guests developed classic cases of "Mexicali revenge" after being fed local produce. At night, films would be shown, courtesy of LBJ friend Arthur Krim, who would have the newest releases flown down. Johnson also loved to visit Alemán's ranch, Las Pampas, deep in the Mexican interior, enjoying the total isolation and rugged beauty of the place. He was moved by the poverty of some of the ranch hands, who almost invariably had large families. Using an interpreter, Johnson would lecture the wives about birth control and the need to have small families if you are poor. Back in Texas, he began sending the families packages of birth control pills, vitamins, clothing, and blankets. "If I became dictator of the world," he said, "I'd give all the poor on earth a cottage, and birth control pills—and I'd make damn sure they didn't get one if they didn't take the other."Each Friday morning, a White House jet landed at the LBJ ranch, depositing foreign policy briefing papers prepared especially for Johnson by Henry Kissinger's staff. On two occasions Kissinger himself arrived at Johnson's door for personal briefings on the peace talks; twice he sent his deputy, General Alexander Haig. In all, LBJ's relations with the Nixon White House were cordial, although he sensed that the briefing papers told him only what Nixon wanted him to know. His death canceled plans he had negotiated with the White House to entertain Israeli Prime Minister Golda Meir in Texas, following her February meeting in Washington with Nixon. Johnson thought it would be a splendid idea to have Mrs. Meir participate in a question-and-answer session with the students of the LBJ School. Through an old supporter, New York industrialist Abe Feinberg, he queried Mrs. Meir on the matter and received word she would be delighted to visit with the students and attend a Johnson-hosted luncheon in Austin. The White House arranged to fly Mrs. Meir to Texas. A few weeks before Johnson's death, Richard Nixon called to tell him that a cease-fire was imminent. Johnson got in touch with his veteran speechwriter, Horace Busby, and asked him to prepare a statement on the cease-fire. "Get this thought in," Johnson instructed Busby. "No man worked harder or wanted peace more than I."Johnson had decidedly mixed emotions about his successor. He was puzzled by Nixon's cold style ("Imagine not inviting one member of Congress to Tricia's wedding. If you don't respect them, they won't respect you") and aghast at some of Nixon's domestic policies. Shortly after leaving the White House, he remarked to a Texas businessman: "When I took over the presidency, Jack Kennedy had left me a stock market of 711. When I left the White House, it was over 900. Now look at it. That's what happens when the Republicans take over—not only Nixon, but any of them. They simply don't know how to manage the economy. They're so busy operating the trickle-down theory, giving the richest corporations the biggest break, that the whole thing goes to hell in a handbasket." Amused staffers recall that on the trip back to Texas aboard Air Force One, Johnson went up and down the aisles giving financial advice: "Keep all your money in cash," he urged. "Nixon will have us in an inflationary recession before his first year is over." (He had also, he told me, given his outgoing Cabinet members a different, if equally sobering, kind of advice: "Each of you had better leave this town clean as Eisenhower's hound's tooth. The first thing Democrats do when they take power is find where the control levers are. But the first thing Republicans do is investigate Democrats. I don't know why they do it but you can count on it.")Johnson gave Nixon "high grades" in foreign policy, but worried intermittently that the President was being pressured into removing U.S. forces too quickly, before the South Vietnamese were really able to defend themselves. "If the South falls to the Communists, we can have a serious backlash here at home," he warned. "When you think of what the South has been through, and what the government is up against, it is nothing short of a miracle that they have kept everything together for as long as they have. Thieu's no saint, but you have got to respect his ability to keep things together under the worst conditions imaginable." Over a lunch, at which I was a guest, a few days after the first installments of the Pentagon Papers appeared in the New York Times, Johnson ruminated about his own Vietnam policies. "We made a couple of key mistakes," he admitted. "To begin with, Kennedy should have had more than eighteen thousand military advisers there in the early 1960s. And then I made the situation worse by waiting eighteen months before putting more men in. By then, the war was almost lost. Another mistake was not instituting censorship—not to cover up mistakes, but to prevent the other side from knowing what we were going to do next. My God, you can't fight a war by watching it every, night on television."He then launched into a long defense of his policies against the allegations and implications contained in the Times's articles. "All the time, in 1964, I really hoped we could negotiate our way out of a major war in Vietnam," he said. "The Russians shared our hope." As the situation deteriorated in Vietnam, he said, he tried, by proceeding with U.S. troop buildups quietly and slowly, to avoid inflaming hawk sentiment at home and, perhaps more important, forcing Hanoi to call on the Chinese for help. "I told my advisers, 'By God, don't come to me with any plans to escalate this war unless you carry with you a joint congressional resolution.' I wasn't going to follow Truman's mistake in Korea when he went in without congressional approval. They claim I used Tonkin Gulf as an excuse. Hell, the Communists hit us there twice. The first time their torpedo boats hit the day before, I did nothing, hoping it was either a mistake or the action would not be repeated. But when they hit us again the very next day, I was forced to act. And just about every member of Congress was marching right along with me." He was particularly ruffled by the accusation that he had been secretly planning to bomb the North at the time of the 1964 campaign, when Barry Goldwater was calling for precisely such an act. "It is absolutely untrue," Johnson said. "On at least five occasions I personally vetoed military requests for retaliation bombing raids in the North. Only late in 1965 did I reluctantly agree to it. Not one of my principal advisers—Rusk, McNamara, Bundy, and George Ball—opposed my decision not to rush into retaliation strikes. We had contingency plans to bomb in the North for retaliation for terrorist raids in the South. But I didn't want to do this. Finally, they attacked our base in Pleiku in February, 1965, destroying many planes and killing a lot of our men. I was forced to act. I felt I had no choice. All of my civilian advisers, every one of them, agreed with me. Dean Rusk told me, 'Mr. President, this is a momentous decision.' I suppose it was."We were in a private dining room on the third floor of the LBJ Library. Across the hall was a replica of Johnson's White House office. A three-foot electric pepper mill sat at the head of the table, and butler Wong scurried in with a plate of steak and sweet corn. Johnson seated himself ahead of his guests, a presidential practice carried into retirement, and began to eat. Aides arrived to whisper in his ear about incoming calls. He either shook his head or left the table for many minutes. Secret Service agents haunted the surrounding corridors, walkie-talkies in hand. Déjà vu was a decorative theme: on one wall of the dining room were the framed photographs of heads of state whom Johnson visited during his years in office. "Here's my favorite," said Lady Bird, pointing to a photo of South Korea's President, General Chung Hee Park. "He was a real no-nonsense fellow." (Lady Bird was more conservative than the public ever realized.) LBJ laughed. "I remember our trip to Seoul. My God, I've never seen so many people lining the streets. I asked Park, through an interpreter, what would he estimate the crowd to be? The interpreter jabbers a bit and tells me, 'President Park, he say population of Seoul is one million. People on the streets is one million. That's all the people we have. So solly.'"During coffee, the talk turned to President Kennedy, and Johnson expressed his belief that the assassination in Dallas had been part of a conspiracy. "I never believed that Oswald acted alone, although I can accept that he pulled the trigger." Johnson said that when he had taken office he found that "we had been operating a damned Murder Inc. in the Caribbean." A year or so before Kennedy's death a CIA-backed assassination team had been picked up in Havana. Johnson speculated that Dallas had been a retaliation for this thwarted attempt, although he couldn't prove it. "After the Warren Commission reported in, I asked Ramsey Clark [then Attorney General] to quietly look into the whole thing. Only two weeks later he reported back that he couldn't find anything new." Disgust tinged Johnson's voice as the conversation came to an end. "I thought I had appointed Tom Clark's son—I was wrong."Johnson rarely worked at the LBJ Library, preferring instead to do business at his comfortable ranch office, where on the wall opposite his large desk hung a painting of a Texas landscape by artist Peter Hurd. At Lady Bird's behest, Hurd had been commissioned to paint the official presidential portrait, resulting in what Johnson called "the ugliest picture I ever saw." Reminiscing, Johnson explained: "He didn't follow the strict rules about size and style laid down about those portraits. I like his scenes much better."In March, 1970, Johnson was hospitalized at Brooke Army Medical Center in San Antonio, after complaining of severe chest pains. Doctors reassured him that he had not suffered a heart attack; instead, the pains were caused by angina, a hardening of the arteries to the heart resulting in an insufficiency of blood to the body's most vital organ. Although there was little that could be done to cure the condition, Johnson was urged to lose considerable weight. He had grown dangerously heavier since leaving the White House, gaining more than twenty-five pounds and weighing around 235. The following summer, again gripped by chest pains, he embarked on a crash water diet, shedding about fifteen pounds in less than a month. But shortly before Christmas, 1971, he shocked his friends by suddenly resuming cigarette smoking, a habit he had discarded over fifteen years before, following his first, near fatal, heart attack. "I'm an old man, so what's the difference?" he explained. "I've been to the Mayo Clinic twice and the doctors tell me there is nothing they can do for me. My body is just aging in its own way. That's it. And I always loved cigarettes, missed them every day since I quit. Anyway, I don't want to linger the way Eisenhower did. When I go, I want to go fast." He quickly became a chain smoker.In April, 1972, Johnson experienced a massive heart attack while visiting his daughter, Lynda, in Charlottesville, Virginia. Convinced he was dying, he browbeat Lady Bird and his doctors into allowing him to fly home to Texas. So, late in the night of his third day in intensive care, a desperately sick LBJ was rushed to the airport and ferried back to Brooke Army Medical Center in San Antonio. The departure was so sudden that the Charlottesville hospital director, hearing a rumor that Johnson might try to leave, rushed to the hospital only to find LBJ's empty wheelchair in the parking lot.Miraculously he survived, but the remaining seven months of his life became a sad and pain-wracked ordeal. "I'm hurting real bad," he confided to friends. The chest pains hit him nearly every afternoon—a series of sharp, jolting pains that left him scared and breathless. A portable oxygen tank stood next to his bed, and Johnson periodically interrupted what he was doing to lie down and don the mask to gulp air. He continued to smoke heavily, and, although placed on a low-calorie, low-cholesterol diet, kept to it only in fits and starts.Meanwhile, he began experiencing severe stomach pains. Doctors diagnosed this problem as diverticulosis, pouches forming on the intestine. Also symptomatic of the aging process, the condition rapidly worsened and surgery was recommended. Johnson flew to Houston to consult with heart specialist Dr. Michael De Bakey, who decided that Johnson's heart condition presented too great a risk for any sort of surgery, including coronary bypass of two almost totally useless heart arteries."I once told Nixon," he said, "that the presidency is like being a jackass caught in a hailstorm. You've got to just stand there and take it. That's what I'm doing now." But he was also busy preparing his estate for his death. During the four years of his retirement he had managed nearly to double his considerable estate, which included stock in at least nine Texas banks, television interests in Texas, Oklahoma, and Louisiana, a real estate and photographic supply company in Austin, 3700 acres of land in Alabama, and extensive property holdings in Mexico, the Caribbean, and five Texas counties.The flagship of Johnson's business empire had been the Austin television station, KTBC, which Lady Bird had launched in 1952, nine years after she bought radio station KTBC. In September, 1972, LBJ engineered the station's sale to the Los Angeles Times-Mirror Corporation for nine million dollars, a premium price which impressed several of Texas' shrewdest horse traders. The sale provided Lady Bird with $4.7 million, and the two Johnson daughters with $1.3 million each. Working with his most trusted assistant, twenty-nine-year-old Tom Johnson, who had served as assistant White House press secretary (and is the newly appointed editor of the Dallas Times-Herald), LBJ negotiated with the National Park Service to take over his ranch home as a national museum after his death and when Lady Bird no longer desired to live there. Most poignant of all, he began a series of tough bargaining sessions with a Tulsa land company to sell the working portion of his beloved ranch. Surprisingly, these financial moves were made without the assistance of his lifelong business partner, Judge A. W. Moursund. "The judge and I have split the blanket," Johnson said. And that is all he would say.Apparently the two had argued about the purchase of a bank, but, whatever the reason, Johnson and Moursund, a Blanco County judge whom LBJ had known since boyhood and who during LBJ's' presidential years had a direct White House line plugged into his hill country ranch, remained totally estranged for the last year of Johnson's life. The split-up offered a rare peek inside Johnson's complicated business empire. Holdings and liabilities jointly filed included more than $700,000 in loans from federal land banks in Texas, Oklahoma, and Kansas. Dividing property, Johnson received a 4000-acre ranch and 214 subdivision lots along Lake LBJ in Austin; while the judge received 3200 acres in Oklahoma and more than 2000 acres in a nearby Texas county. All of the loans were listed in the names of Moursund and his wife.Sick and depressed, Johnson had hoped to attend the 1972 Democratic National Convention in Miami Beach, if only to stand up and take a bow. He needed some warmth and applause, but from Larry O'Brien and others the message filtered back that he had better stay home. The McGovern nomination disgusted him. Nixon could be defeated if only the Democrats don't go too far left," he had insisted. But to Johnson, party loyalty ranked with mother love, so he was far from pleased to find such old colleagues as George Christian, Leonard Marks, and former Commerce Secretary C. R. Smith working for Nixon against other old friends such as Liz Carpenter and Joe Califano, who campaigned for McGovern. Of John Connally, with whom his relationship had long been complicated, and who he thought would run on the GOP ticket as Nixon's running mate, Johnson remarked philosophically: "John sees a good opportunity." But when another close Texas confidant stretched his endorsement of Nixon to include active support for Texas Republican Senator John Tower, Johnson angrily called the offender and exploded: "You're a fat old whore."Johnson's choice to beat Nixon was Edmund Muskie. In his view, Senator Muskie was "crucified by the press. They zeroed in on him because he was the front-runner and pounded him out, just like they did to Romney in 1964." His disappointment was mollified slightly by his own estimations of the Maine senator, which he had discussed with friends a few years before. "Muskie," he had said, "will never be President because he doesn't have the instinct to go for his opponent's jugular." Prior to the convention, Johnson held long telephone conversations with both Muskie and Chicago's Mayor Daley on the strategy to stop McGovern. He advised Muskie to stand firm and hold out to see whether there would be a second ballot. But he refused to act on Daley's plea that he, Johnson, take an initiative and speak out against McGovern. "Johnson knows that if he takes such a stand it will be counterproductive," a friend said at the time. "If he goes against McGovern, it will only boost McGovern's stock. Lyndon just doesn't carry any weight in the party anymore, and he knows it. It's a miserable fact for a man who only four years ago was President of the United States. But it is a fact."So Johnson suffered the election in silence, swallowing his nitroglycerin tablets to thwart continual chest pains, endorsing McGovern through a hill country weekly newspaper, meeting cordially with the candidate at the ranch. The newspapers showed a startling picture of Johnson, his hair almost shoulder-length. Former aide Bob Hardesty takes credit for this development. "We were working together one day," Hardesty recalls, "and he said, in passing, 'Robert, you need a haircut.' I told him, 'Mr. President, I'm letting my hair grow so no one will be able to mistake me for those SOB's in the White House.' He looked startled, so I explained, 'You know, that bunch around Nixon—Haldeman, Ehrlichman—they all have very short hair.' He nodded. The next time I saw him his hair was growing over his collar."During the final months of his life he was suffering terrible pain. One of his last public appearances, his dramatic speech at the Civil Rights Symposium at the LBJ Library, proved to be so exhausting that he spent the next two days in bed. He filmed a final interview with Cronkite, taking long rests between camera loadings. Against the urgings of his wife and friends, he attended the mass funeral of fourteen Austin youngsters killed in a bus crash. "Those people supported me when I needed them over the years," he insisted, "and I'm going to support them now."Lady Bird noticed that he was unusually quiet on that cold January morning, but nothing seemed wrong, so she decided to drive into Austin for shopping. At mid-afternoon, on January 22, the Secret Service placed an urgent call to her via the car-telephone, and Lady Bird, in a shaking voice, called aide Tom Johnson at the television station. "Tom," she said, "this time we didn't make it. Lyndon is dead."FOOTNOTE:One of the more secretive Presidents, Johnson nevertheless was unexpectedly willing to open up portions of his archives to scholars as quickly as possible. At the time of his death, he had arranged for the LBJ Library curator to meet at the White House with Nixon's then chief of staff, H. R. Haldeman, to discuss declassification of Johnson's foreign policy papers. The basis of the meeting was Nixon's new executive order providing more flexible guidelines on declassifying documents. LBJ hoped his papers would meet these new guidelines.Copyright (c) 2018 by The Atlantic Monthly Group. All Rights Reserved.

Individual retirement accountAn individual retirement account (IRA) is a form of "individual retirement plan", provided by many financial institutions, that provides tax advantages for retirement savings in the United States. An individual retirement account is a type of "individual retirement arrangement" as described in IRS Publication 590, individual retirement arrangements (IRAs). The term IRA, used to describe both individual retirement accounts and the broader category of individual retirement arrangements, encompasses an individual retirement account; a trust or custodial account set up for the exclusive benefit of taxpayers or their beneficiaries; and an individual retirement annuity, by which the taxpayers purchase an annuity contract or an endowment contract from a life insurance company.To answer this question, there should be more information: are you at fault? do you have insurance? how old are you? are you retired?, and would this be a withdrawal from a ROTH IRA?. So let’s start with the accident:If you cause the accidentIn most states, if you cause an accident, your insurance company pays for the damage and injury costs of victims. If you have no insurance, the victims might sue you. The process is different in the 12 “no-fault” insurance states. Drivers make claims through their own insurance for minor injuries, no matter who caused the crash. This means other people may not be able to sue you for medical costs unless the injuries are severe or the tab reaches a significant amount. Each state sets its own rules for the situations in which legal action is allowed.If someone else causes the accidentThose with no insurance may be limited in what they can sue the at-fault driver for, depending on the state.If you live in a state with “no pay, no play” laws, uninsured drivers are prevented from suing for damages that can’t be quantified with a dollar amount. These include physical pain, emotional distress, and mental suffering.Uninsured motorists in “no pay, no play” states also may have to pay a massive deductible toward repairs before they can sue for property damage costs — that is $25,000 in Louisiana, for example.States with “no pay, no play” laws are:AlaskaCaliforniaIndianaIowaKansasLouisianaMichiganMissouriNorth DakotaNew JerseyOklahomaOregonCar insurance is usually requiredAlmost every state requires drivers to prove they can take financial responsibility if they cause a crash. That often means buying car insurance, although some states allow a bond or cash deposit.Alaska and New Hampshire are special cases. Alaska doesn’t require insurance in places where registering your car is optional; people in other parts of the state do need coverage. New Hampshire doesn’t mandate auto insurance for residents with clean driving records and only requires proof of financial responsibility after a crash.» MORE: States where you might not have to get car insurancePenalties for getting caught without insuranceWhether you cause a car accident or not, if you’re caught driving without insurance or other proof of financial responsibility, you could face a wide range of consequences.For example, first-time offenders in Texas face a fine of at least $175. But in Minnesota, the same offense could carry a fine of up to $1,000, up to 90 days in jail and loss of your license and registration.Check out this list of penalties for driving without insurance compiled by the Consumer Federation of America for a state-by-state breakdown.If you have insurance, but no proofYou should keep proof of insurance, such as the policy ID card, in your vehicle. Some states allow you to show proof of insurance on your smartphone.If you cause an accident but have no proof of insurance, it’s less serious than being uninsured. You may get a citation but could potentially get it dismissed by showing proof of insurance in court.An accident with no insurance hurts future ratesWe analyzed rates for drivers in California, Illinois, and Texas who had caused an accident and were uninsured. We compared those rates with prices for drivers with clean records.Car insurance prices if you cause an accident without insuranceStateThe average rate for good driversAverage rate with one at-fault crashAverage rate with one at-fault crash and no proof of insuranceCalifornia$1,293 per year$2,016 per year$2,084 per yearIllinois$1,029 per year$1,389 per year$1,409 per yearTexas$1,429 per year$2,010 per year$2,092 per yearRates for drivers who crashed without proof of insurance were significantly higher than rates for good drivers. To a lesser degree, they were also higher than the rates for insured drivers who had caused an accident.An IRA is a type of investment vehicle that allows you to earn money tax-free until you withdraw the funds. ... If you simply deposit money into your IRA, you won't make much of anything. Once you deposit the money, go in and invest with the help of a financial professional if needed.In addition, with a Traditional IRA, you may get a tax deduction when you contribute to it, and with a Roth IRA, can withdraw money from it tax-free once you reach retirement age. Still, despite the benefits that IRAs offer, there are a number of good reasons you might be better of not putting money into your IRA. The tax advantages of an IRA can have a dramatic impact on savings over the course of several decades. While anyone can contribute up to $5,500 (or $6,500 for individuals age 50 and older) to a traditional IRA, and $6,000 in 2019, not everyone can deduct that full amount on their tax return.Can I contribute to an IRA if I am not working?Under current laws, if you're married filing jointly, you can contribute the maximum into an IRA for each spouse—even if one of you has no earned income—as long as the working spouse has income equal to both contributions. ... That's because once opened, a spousal IRA is an Individual Retirement Account like any other. Yes, you can contribute to both a Roth IRA and an employer-sponsored retirement plan such as a 401(k), SEP or SIMPLE IRA, subject to income limits. However, each type of retirement account has annual contribution limits.Can I contribute more than 5500 to my IRA?Any year in which you contribute to a Roth even though you make too much to qualify—or if you contribute more than permitted—you've made an ineligible (excess) contribution. ... The $6,000 (or $7,000) figure above is the maximum you can contribute in 2019 to either or both a Traditional and a Roth IRA.Technically, you can't borrow against your IRA or take a loan directly from it. ... Essentially, money taken out of an IRA can be put back into it or another qualified tax-advantaged account within 60 days, without taxes and penaltiesShould I withdraw from IRA to pay off debt?A: Yes, you can withdraw money from your Roth IRA to pay off debt. But it is rarely a good idea to tap money earmarked for your retirement. First, you should understand the rulesHow can I take money from my IRA without penalty?Delay IRA withdrawals until age 59 1/2. Once you turn age 59 1/2, you can withdraw any amount from your IRA without having to pay the 10 percent penalty. However, regular income tax will still be due on each withdrawalThere are so many rules when it comes to an IRA, that it seems a definitive no, at first to your question, but after much research, I seem to have found a loophole without breaking the rules. I am going to include that copy below, for those who are interested. I warn you from now that it is a lot of information, but it is good information to have at your fingertips. I have given you short simple answer’s above to basic, short, simple questions- I hope that you find it useful. Thanks for the question:How to Use Your Roth IRA as an Emergency FundBY AMY FONTINELLEUpdated Nov 5, 2018Ever feel like you don’t have enough money to save for emergencies and also save for retirement? Keeping the money in your bank account makes it easily accessible if you suddenly need a pile of cash to fix your car, cover unexpected medical bills or deal with unemployment. Putting money in a retirement account, on the other hand, comes with rules that can make it difficult to get your hands on your cash should you suddenly need it. These structures are one reason people can feel understandably reluctant to put too much in a retirement account like an IRA or 401(k), even though we know a comfortable future depends on it.Good news: An often-overlooked feature of the Roth IRA could solve your problem. Because contributions to a Roth are made with money on which you've already paid taxes, IRS rules allow you to withdraw that money at any time without penalty.By contrast, contributions to traditional IRAs are generally made with pre-tax income. You don't pay tax on that money until you withdraw it at 59½ or older, but if you do decide you need to withdraw it before that age, you pay both income tax on your withdrawal and a 10% penalty.With a Roth, only your Roth’s investment earnings must remain in the account until you’re 59½ in order to avoid paying a 10% penalty. There are limitations on how much you can earn to qualify for a Roth, but if you do qualify, your Roth can give you the safety of knowing that, if you really need it, you have penalty-free access to these savings. Your Roth account can double as a second emergency savings account.How much can you save per year? Subject to income limits, in 2019 a Roth IRA allows you to save as much as $6,000 per year (the 2018 limit is $5,500 ) and still have access to these retirement savings in the event of an emergency If you’re married, you and your spouse can each contribute $6,000, for a total of $12,000 (or $11,000 in 2018). Add an additional $1,000 per person to both 2018 and 2019 contributions if either or both of you are age 50 or older.Remember the biggest benefit: Money in your Roth grows tax-free until retirement. And when you do retire, you pay no taxes on withdrawals. You also won't be mandated to take required minimum distributions (RMDs) from that account; the money can continue to grow tax-free until you need it. (With a traditional IRA, you do pay taxes on withdrawals and taking out a certain amount after age 70½ is required.)All this probably sounds way too far in the future to be important. But trust us, it is. See if you qualify and don’t miss out on making this year’s contribution – it’s an opportunity (and future tax break) you’ll never get back.Here are seven tips for using your Roth IRA as an emergency fund:1. Understand Why You’re Doing ItThe advantage of putting emergency savings into a Roth IRA is that you don't miss the limited opportunity to make that year's retirement contribution. You can only contribute a few thousand dollars to a Roth IRA each year, and once a year passes without a contribution, you lose the opportunity to make it forever.The more money set aside for retirement and the earlier saving is begun, the better. In reality, most people won't have to go back and withdraw money from their Roth, which means they'll have more saved for retirement. And in a worst-case scenario in which money does have to be withdrawn, it can be done without penalty.“Roth IRAs remain the most flexible retirement accounts in the country,” says Jeff S. Vollmer, managing director of Hyde Park Wealth Management in Cincinnati.Accessing these funds, however, should be your last resort.Matt Becker, a fee-only certified financial planner and author of Home, points out that you don’t want to be withdrawing Roth IRA contributions for minor emergencies such as car repairs or small medical bills; you should keep enough in savings for these events. Your Roth IRA emergency fund should be for larger emergencies such as unemployment or a serious illness.Withdrawing Roth contributions is a better option than racking up interest on credit card debt, but it shouldn’t be your sole source of emergency funds. Best is to have a separate emergency fund account as well as the money allocated for emergencies in your Roth.2. Only Withdraw ContributionsThe key to using a Roth IRA as an emergency fund is to avoid withdrawing investment earnings. While you can withdraw contributions at any time without penalty, withdrawal of earnings before age 59½ means you'll have to pay a 10% penalty on that money. Following this rule is simple: Don’t withdraw more than you’ve put in.If you do have to withdraw contributions, you can pay yourself back and retain your Roth contribution for that year if you act fast.“If the emergency turns out to be a short-term cash flow issue that gets resolved quickly, [you] can put the money back into the Roth IRA within 60 days to refund this account,” says certified financial planner Scott W. O'Brien, director of wealth management for WorthPointe Wealth Management in Austin, Texas. Do that and the most you'll lose is a little bit of interest.3. Don’t Invest Emergency Fund Money"It is critical not to invest the portion of your Roth dedicated to your emergency fund,” says Garrett M. Prom, founder of Prominent Financial Planning in Austin, Texas. “This money is for emergencies, which in most cases is job loss. If that job loss is part of a downturn in the economy, you will have to sell investments, usually at a loss.”The part of your Roth IRA contribution earmarked as your emergency fund doesn’t belong in stocks, bonds or mutual funds like a typical retirement contribution. It belongs in a liquid account which still earns a bit of interest, but one from which you can withdraw at a moment’s notice without losing principal. Ally Bank, for example, has an IRA savings account that pays 1.85% interest, as of September 2018.Gains to the Roth account will increase without having to pay taxes on the earnings every year, as would be the case with a regular savings account. You also won’t have to pay tax on these earnings when you withdraw them as qualified distributions once you reach retirement age.A savings account within a Roth can earn at least as much interest as a regular savings account – if not more, depending on where you bank. If you already have a Roth IRA but your brokerage doesn't have any low-risk places to keep your money while still earning interest, open a second Roth IRA at an institution that does. It’s fine to have multiple Roth IRA accounts, as long as your total contributions to all accounts don’t exceed the annual limit.Once you have a large enough emergency fund, start moving those contributions into higher-earning investments; you don't want all of your Roth contributions in cash forever. This process might take you a few months or a few years, depending on how quickly you can accumulate additional savings.4. Don't Withdraw Unseasoned Rollover FundsIf your Roth IRA contains contributions that you converted or rolled over from another retirement account, such as a 401(k) from a former employer, you’ll need to be careful about any withdrawals, because there are special rules about withdrawing rollover contributions. Unless they've been in your Roth for at least five years, you'll incur a 10% penalty if you withdraw them, and each conversion or rollover has a separate five-year waiting period.Withdrawing rollover contributions penalty-free can be tricky, so it’s a good idea to consult a tax professional if you find yourself in this situation. The good news is that if you have both regular contributions and rollover contributions, the IRS first categorizes your withdrawals as withdrawals of regular contributions before it categorizes them as withdrawals of rollover contributions.5. Know How Much Time It Takes to Get Your Contributions BackWhat good is an emergency fund if you can’t access the money when you need it? Funds availability may differ depending on the institution where you keep your Roth and the type of account you place the money in. You don’t want to learn later when you need money urgently, that it will take days to get a check or bank transfer, so find out before making a contribution to your Roth IRA how long it will take to get it back.Funds can typically be retrieved in less than three business days. If you are taking cash out of a money market or mutual fund and you put in your withdrawal request before 4 p.m. EST, you will have the money by the next business day. If the money is invested in stocks, you will need to wait three business days typically, although if you have a checking account with the same company where you have your Roth IRA, you may be able to get it faster.A wire transfer can also be a fast way to access funds, though you’ll have to pay a wire transfer fee that’s typically $25 to $30.“Most brokerage firms can wire funds directly from a Roth IRA to a checking or savings account in one business day, assuming stocks or bonds don't have to be sold to generate cash,” says Accredited Asset Management Specialist Marcus Dickerson of Beaumont, Texas.These potential delays in Roth IRA fund availability are another reason to keep some emergency cash outside of your Roth IRA, in your checking or savings account, for extremely urgent needs.6. Maximize Your ContributionOnce a particular year's deadline passes for contributing to a Roth IRA, you've lost a chance to contribute for that year forever. Since the Roth has a relatively low annual contribution limit, you don't want to miss out on making the full contribution for any year if you can help it.The maximum you can contribute for the year, as of tax year 2019, is the lesser of $6,000, or your taxable compensation for the year. If you’re 50 or older, you can contribute the lesser of $7,000 or your taxable compensation for the year. (The figures for 2018 are $5,500 and $6,500, respectively.)The IRS lowers the Roth IRA contribution limits if your filing status is married filing jointly or qualifying widow(er) and your modified AGI is $193, 000 to $203,000 in 2019 ($189,000 to $199,000 in 2018); if your modified AGI is $203,000 or more ($199,000 or more for 2018), you can’t contribute to a Roth. In 2019 single filers and heads of household hit the reduced contribution threshold at $122,000 and are disqualified once their modified AGI is $137,000 or more (or $120,000 and $135,000, respectively, in 2018).“Don't forget to fund an account for the low wage or nonworking spouse,” says Amy Rose Herrick, a Chartered Financial Consultant and paid tax preparer in Christiansted, Va. “Too many people assume you have to be earning funds to have your own retirement account. This is not true. You can have what is referred to as a spousal Roth IRA based on the earnings of the working spouse.”7. Fill Out the Correct Paperwork at Tax TimeIf you do need to withdraw contributions from your Roth IRA to use in an emergency, there’s paperwork involved. Even though you're allowed to withdraw contributions without penalty, you still have to report your withdrawals to the IRS on part III of form 8606.If you use tax preparation software, it will ask you if you made any withdrawals from a retirement account during the year and guide you through the paperwork. If you use a professional tax preparer, make sure to tell him or her about your withdrawal so he or she can fill out IRS form 8606 for you.If you only put money in your Roth and don’t take anything out, you have nothing extra to do at tax time. You don’t need to report Roth IRA contributions on your tax return since you’ve already paid tax on that income and contributions don’t reduce your taxable income.Also, if you make your Roth contribution before the income tax filing deadline for the year and need to withdraw that money before the filing deadline, the IRS treats these contributions as if you had never made them. You won’t need to report them at tax time.The Bottom Line“The Roth IRA is the perfect place to stow those ‘just in case’ funds while also taking advantage of the opportunity for tax-free growth, and tax-free income, in retirement,” Dickerson says.While the IRS calls the types of withdrawals described in this article “unqualified,” which makes it sound like you’re breaking a rule, it considers them a “return of your regular contributions” and does not tax or penalize them. “Qualified” distributions are simply those that have been in your Roth for at least five years and that you withdraw after age 59½.You have 15½ months each tax year to accumulate emergency funds to place in a Roth. For the tax year 2018, for example, you can make contributions through April 15, 2019. For the tax year 2019, you can make contributions from Jan. 1, 2019 through April 15, 2020.

To the patients health, you mean? I think you need to be more specific with your question.Edited to reflect your comment:There are a lot of factors that make up the cost of healthcare, and certainly to an extent, the cost of patients seeing doctors unnecessarily for visits/tests certainly takes a share of that rising cost.Unfortunately I am unable to really answer this question as I have always worked at not for profit hospitals and healthcare systems and have taken a salary and not charged per patient/procedure.However, here is a great article in the New Yorker Magazine Annals of Medicine on the subject of unnecessary tests and rising healthcare costs which I think you might find interesting and useful.The cost conundrumWhat a Texas town can teach us about HealthcareWritten by Dr. Atul GawandeCostlier care is often worse care. Photograph by Phillip Toledano.It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. “The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.From the moment I arrived, I asked almost everyone I encountered about McAllen’s health costs—a businessman I met at the five-gate McAllen-Miller International Airport, the desk clerks at the Embassy Suites Hotel, a police-academy cadet at McDonald’s. Most weren’t surprised to hear that McAllen was an outlier. “Just look around,” the cadet said. “People are not healthy here.” McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.One day, I went on rounds with Lester Dyke, a weather-beaten, ranch-owning fifty-three-year-old cardiac surgeon who grew up in Austin, did his surgical training with the Army all over the country, and settled into practice in Hidalgo County. He has not lacked for business: in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it. I walked around with him as he checked in on ten or so of his patients who were recuperating at the three hospitals where he operates. It was easy to see what had landed them under his knife. They were nearly all obese or diabetic or both. Many had a family history of heart disease. Few were taking preventive measures, such as cholesterol-lowering drugs, which, studies indicate, would have obviated surgery for up to half of them.Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)Was the explanation, then, that McAllen was providing unusually good health care? I took a walk through Doctors Hospital at Renaissance, in Edinburg, one of the towns in the McAllen metropolitan area, with Robert Alleyn, a Houston-trained general surgeon who had grown up here and returned home to practice. The hospital campus sprawled across two city blocks, with a series of three- and four-story stucco buildings separated by golfing-green lawns and black asphalt parking lots. He pointed out the sights—the cancer center is over here, the heart center is over there, now we’re coming to the imaging center. We went inside the surgery building. It was sleek and modern, with recessed lighting, classical music piped into the waiting areas, and nurses moving from patient to patient behind rolling black computer pods. We changed into scrubs and Alleyn took me through the sixteen operating rooms to show me the laparoscopy suite, with its flat-screen video monitors, the hybrid operating room with built-in imaging equipment, the surgical robot for minimally invasive robotic surgery.I was impressed. The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don’t. But that rule doesn’t hold for health care.At McAllen Medical Center, I saw an orthopedic surgeon work under an operating microscope to remove a tumor that had wrapped around the spinal cord of a fourteen-year-old. At a home-health agency, I spoke to a nurse who could provide intravenous-drug therapy for patients with congestive heart failure. At McAllen Heart Hospital, I watched Dyke and a team of six do a coronary-artery bypass using technologies that didn’t exist a few years ago. At Renaissance, I talked with a neonatologist who trained at my hospital, in Boston, and brought McAllen new skills and technologies for premature babies. “I’ve had nurses come up to me and say, ‘I never knew these babies could survive,’ ” he said.And yet there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.“It’s malpractice,” a family physician who had practiced here for thirty-three years said.“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?“Practically to zero,” the cardiologist admitted.“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.In an odd way, this news is reassuring. Universal coverage won’t be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with. So the idea that there’s plenty of fat in the system is proving deeply attractive. “Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated.Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.I had what I considered to be a reasonable plan for finding out what was going on in McAllen. I would call on the heads of its hospitals, in their swanky, decorator-designed, churrigueresco offices, and I’d ask them.The first hospital I visited, McAllen Heart Hospital, is owned by Universal Health Services, a for-profit hospital chain with headquarters in King of Prussia, Pennsylvania, and revenues of five billion dollars last year. I went to see the hospital’s chief operating officer, Gilda Romero. Truth be told, her office seemed less churrigueresco than Office Depot. She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience. And when I inquired, “What is going on in this place?” she looked surprised.Is McAllen really that expensive? she asked.I described the data, including the numbers indicating that heart operations and catheter procedures and pacemakers were being performed in McAllen at double the usual rate.“That is interesting,” she said, by which she did not mean, “Uh-oh, you’ve caught us” but, rather, “That is actually interesting.” The problem of McAllen’s outlandish costs was new to her. She puzzled over the numbers. She was certain that her doctors performed surgery only when it was necessary. It had to be one of the other hospitals. And she had one in mind—Doctors Hospital at Renaissance, the hospital in Edinburg that I had toured.She wasn’t the only person to mention Renaissance. It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) Romero and others argued that this gives physicians an unholy temptation to overorder.Such an arrangement can make physician investors rich. But it can’t be the whole explanation. The hospital gets barely a sixth of the patients in the region; its margins are no bigger than the other hospitals’—whether for profit or not for profit—and it didn’t have much of a presence until 2004 at the earliest, a full decade after the cost explosion in McAllen began.“Those are good points,” Romero said. She couldn’t explain what was going on.The following afternoon, I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”Then why do hospitals in McAllen order so much more surgery and scans and tests than hospitals in El Paso and elsewhere?In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.“Do we provide better health care than El Paso?” Gelman asked. “I would bet you two to one that we do.”It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.And, I realized, few people in their position do. Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.Why? Some of it could reflect differences in training. I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I’d been trained. But the doctor in Alexandria was going to send Walker home. That was how he’d been trained. Suppose things change for the worse? I asked him. It’s extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”“How much?” I asked.“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.“I’ll be there,” the cardiologist said.Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.“Medicine has become a pig trough here,” he muttered.Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.How about doing the opposite and increasing the role of big insurance companies?“What good would that do?” Dyke asked.The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.Source: http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum